When billing, you must use the most appropriate code as of the effective date of the submission. If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Otherwise, you are responsible for the full cost of any care you receive out of network. You pay your plans copayments, coinsurance and deductibles for your network level of benefits. When you need emergency care (for example, due to a heart attack or car accident), go to any doctor, walk-in clinic, urgent care center or emergency room. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. All Rights Reserved. She loves that her building has a gym and pool because she likes to stay in shape. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. Applicable FARS/DFARS apply. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. An example of how it works: Courtney, 43, is a single lawyer who just bought her first home, a condo in Midtown Atlanta. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. When you have no choice, we will pay the bill as if you got care in network. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Visit the secure website, available through www.aetna.com, for more information. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. CPT is a registered trademark of the American Medical Association. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. Well review the information when the claim comes in. The information on this page is for plans that offer both network and . For example, if you have a $1000 deductible, you . Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Treating providers are solely responsible for medical advice and treatment of members. Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). New and revised codes are added to the CPBs as they are updated. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. You must meet it before the plan pays benefits (except for in-network preventive care and preventive generic drugs). You have this coverage while you are near your home or traveling. Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. CPT only Copyright 2020 American Medical Association. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. Your benefits plan determines coverage. You pay your coinsurance or copay along with your deductible. The member's benefit plan determines coverage. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. For those plans, out-of-network care is covered only in an emergency. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Please complete the form, or call Member Services to give us the information over the phone. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. , Medicare-based rates, which are determined and maintained by the government, Reasonable,, usual and customary and prevailing charges, which are obtained from a database of provider charges. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. You are covered for emergency care. A deductible is the amount you pay out-of-pocket for covered services before your health plan kicks in. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. Some plans do not offer any out-of-network benefits. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. This plan carries a high deductible ($1,500 for individuals, $3,000 for family). Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Treating providers are solely responsible for dental advice and treatment of members. A health insurance deductible is a specified amount or capped limit you must pay first before your insurance will begin paying your medical costs. NOTE: Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the plan year. The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. Applicable FARS/DFARS apply. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. All services deemed "never effective" are excluded from coverage. That includes students who are away at school. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Unlisted, unspecified and nonspecific codes should be avoided. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Covered only in an emergency coverage for services or supplies that Aetna considers medically necessary subject! 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